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Equipment Inquiry

Please tell us more about how Colton’s Encouragement can enable and empower you!

Name

First Name

Last Name

Name of Guardian (if applicable)

First Name

Last Name

Email

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Information

What is the medical diagnosis? Has it been suggested by a medical professional that this equipment is necessary for your mobility?

Equipment Information

Please state equipment needed, including the brand and approximate cost (or balance owed).

Insurance Information

Have you filed for insurance coverage? Was this piece of equipment denied or partially covered by insurance?

4802 119th Street

Lubbock, TX 79424

(806)778-3193

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